Student signature and date: ___
Signature Date
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Student signature and date: ___
Cij Home Address: Street City State Zip
OFFICE OF Student Name: ___ CWID: ___
THE REGISTRAR Home Address: ___ Street City State Zip
Term:_____
Home Phone: (___) ___
Phone: 502-597-6340
Fax: 502-597-6239 Home Phone: (____) _____
Email address:_____
Cell Phone: (___) ___
Students who receive Title IV financial aid Pell Grant, Federal SEOG, Federal Perkins Loan, Federal Direct or PLUS loans and withdraw from the University are subject to the Return of Title IV Funds regulations. Students with funds from any of these programs “earn” their financial aid dollars while enrolled. If a student withdraws prior to completing 60% of a term, a prorated portion of his/her federal financial aid dollars must be considered “unearned” and returned to the federal programs. Unearned financial aid dollars returned to the federal programs could cause students to owe the University a significant amount upon withdrawal. Failure to return aid due back to their federal programs will result in loss of eligibility for federal financial aid assistance. Unpaid delinquent amounts may result in collection procedures.
The student will be responsible for any outstanding balance. Withdrawal does not cancel a bill.
I have read this statement and understand it. Student's initials: _____ Date: _____
Are you a veteran?
Yes _____ No _____
Are you receiving veteran's benefits?
Yes _____ No _____
For use by the Office of the Registrar - Do not write below this line.
Term: _____ Reason(s) for withdrawal: _____
If the student refuses to complete the withdrawal form or is at a distance from the University, someone in the Office of the Registrar will complete the form.
This form has been completed without the student's signature? Yes _____ No _____
Reason: ___ student refused to complete form ___ online or virtual student other: ___
Form Revised 2/2009